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Pereira-Macedo J, Silva AF, Duarte-Gamas L, Andrade JP, Sousa-Pinto B, Rocha-Neves J. Incidence of myocardial injury in patients submitted to carotid endarterectomy. VASA 2024; 53:13-27. [PMID: 37987782 DOI: 10.1024/0301-1526/a001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Myocardial injury following noncardiac surgery (MINS) is associated with higher mortality and major adverse cardiovascular event rates in the short- and long-term in patients undergoing carotid endarterectomy (CEA). However, its incidence is still unclear in this subset of patients. Therefore, this systematic review with meta-analysis aims to determine the incidence of MINS in patients undergoing CEA. Three electronic databases MEDLINE, Scopus, and Web of Science were used to search for studies assessing the occurrence of MINS in the postoperative setting of patients undergoing CEA. The incidence of MINS was pooled by random-effects meta-analysis, with sources of heterogeneity being explored by meta-regression and subgroup analysis (general anesthesia vs. regional anesthesia). Assessment of studies' quality was performed using National Heart, Lung, and Blood Institute Study Quality Assessment Tool, and Risk of Bias 2 tools. Twenty studies were included, with a total of 117,933 participants. Four of them were RCTs, while the remaining were cohort studies. All observational cohorts had an overall high risk of bias, except for Pereira Macedo et al. Three of them had repeated population, thus only data from the most recent one was considered. On the other hand, all RCT had an overall low risk of bias. In patients under regional anesthesia, the incidence of MINS in primary studies ranged between 2% and 15.3%, compared to 0-42.5% for general anesthesia. The meta-analytical incidence of MINS after CEA was of 6.3% [95% CI 2.0-10.6%], but severe heterogeneity was observed (I2=99.1%). MINS appears to be relatively common among patients undergoing CEA. The observed severe heterogeneity points to the need for further larger studies adopting consistent definitions of MINS and equivalent cut-off values.
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Affiliation(s)
- Juliana Pereira-Macedo
- Department of Surgery, Hospitalar Centre of Medio-Ave, Vila Nova de Famalicão, Portugal
- Department of Angiology and Vascular Surgery, University Hospitalar Centre of Sao Joao, Porto, Portugal
- Faculty of Medicine of University of Porto, Portugal
| | | | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, University Hospitalar Centre of Sao Joao, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine, Unity of Anatomy, Faculty of Medicine, University of Porto, Portugal
- CINTESIS@RISE - Centre for Health Technology and Services Research, Porto, Portugal
| | - Bernardo Sousa-Pinto
- CINTESIS@RISE - Centre for Health Technology and Services Research, Porto, Portugal
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, University Hospitalar Centre of Sao Joao, Porto, Portugal
- Department of Biomedicine, Unity of Anatomy, Faculty of Medicine, University of Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Portugal
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Galyfos G, Liakopoulos D, Sigala F, Filis K. New paradigms in minimally-invasive vascular surgery. Expert Rev Cardiovasc Ther 2022; 20:207-214. [PMID: 35341434 DOI: 10.1080/14779072.2022.2058492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Vascular surgery has been greatly evolved during the last decades and novel minimally invasive techniques have been introduced. Aim of this review is to briefly present all these advances and compare them with traditional repairs. AREAS COVERED The authors have extensively searched literature through the Pubmed and Embase databases. All articles published up to December 2021 referring to minimally invasive techniques used for treatment of peripheral artery disease, carotid disease, aortic aneurysms and venous disease were evaluated. Minimally invasive techniques under investigation included endovascular and hybrid techniques, robot-assisted and laparoscopic approaches. EXPERT OPINION Several minimally invasive techniques such as endovascular and hybrid approaches have been extensively used during the last two decades to treat vascular surgery patients offering them lower mortality and morbidity risks. Novel robot assisted techniques have shown promising results in preclinical studies although further clinical evaluation is needed.
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Tyson AC, Parikh S, Singh K, Zia S, Deitch JS, Schor JA. Routine Postoperative Cardiac Testing is Unnecessary after Carotid Endarterectomy. Ann Vasc Surg 2019; 59:12-15. [PMID: 30769059 DOI: 10.1016/j.avsg.2018.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/05/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is common in many centers. Its use in this patient population has not been thoroughly investigated. We hypothesize that routine testing for MI in post-CEA patients is of low yield and not cost-effective. METHODS A retrospective review of 291 consecutive CEAs from February 2011 to July 2015 was performed. Two patients were excluded: one for postoperative noncardiac death and one for preoperative MI. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were reviewed. All patients had troponin-I and creatine kinase-MB levels taken postoperatively. A patient was judged to have an MI if troponin-I was greater than or equal to 0.6 ng/mL or CK-MB is >6.3 ng/mL. The incidence of postoperative MI was recorded, and a cost analysis was performed. RESULTS The mean age was 70.2 years (range: 42-92). Of all, 59.5% were male, and 92.4% had a history of hypertension. Preoperatively, 57.4% were on beta-blocker therapy, 86.5% on aspirin, and 52.2% on both. Most (80.6%) were on preoperative statin therapy, 26.9% had a prior history of MI (37.2% within 5 years of surgery), and 56.4% of patients had a prior coronary intervention (27.6% percutaneous, 28.7% coronary artery bypass grafting, and 11% both). All patients received general anesthesia. The mean procedure time was 121.5 min (range: 62-258). The mean postoperative length of stay was 2.6 days. Eight patients (2.7%) were judged to have acute MI, one of which was symptomatic. Three of the 8 (38%) had a prior history of MI. In asymptomatic patients, the peak level of troponin-I ranges from 0.52 to 3.64 ng/mL and that of CK-MB from 11.8 to 24 ng/mL. The symptomatic patient had chest pain and bradycardia. The patient had a peak troponin-I level of 1.59 ng/mL, with a CK-MB level of 11.5 ng/mL. All patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing in patients who underwent CEA would have saved an estimated $51,343 over the course of treatment of the studied population. CONCLUSIONS Routine postoperative cardiac laboratory testing in asymptomatic patients after CEA increases the hospital cost. The low overall rate of postoperative MI suggests that cardiac testing is best reserved for symptomatic patients or those with clinical suspicion for MI.
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Affiliation(s)
| | | | - Kuldeep Singh
- Staten Island University Hospital, Staten Island, NY
| | - Saqib Zia
- Staten Island University Hospital, Staten Island, NY
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Kwon H, Moon DH, Han Y, Lee JY, Kwon SU, Kang DW, Choo SJ, Kwon TW, Kim MJ, Cho YP. Impact of subclinical coronary artery disease on the clinical outcomes of carotid endarterectomy. J Neurosurg 2016; 126:1560-1565. [PMID: 27257829 DOI: 10.3171/2016.3.jns16287] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Controversy persists regarding the optimal management of subclinical coronary artery disease (CAD) prior to carotid endarterectomy (CEA) and the impact of CAD on clinical outcomes after CEA. This study aimed to evaluate the short-term surgical risks and long-term outcomes of patients with subclinical CAD who underwent CEA. METHODS The authors performed a retrospective study of data from a prospective CEA registry. They analyzed a total of 702 cases involving patients without a history of CAD who received preoperative cardiac risk assessment by radionuclide myocardial perfusion imaging (MPI) and underwent CEA over a 10-year period. The management strategy (the necessity, sequence, and treatment modality of coronary revascularization and optimal perioperative medical treatment) was determined according to the presence, severity, and extent of CAD as determined by preoperative MPI and additional coronary computed tomography angiography and/or coronary angiography. Perioperative cardiac damage was defined on the basis of postoperative elevation of the blood level of cardiac troponin I (0.05-0.5 ng/ml) in the absence of myocardial ischemia. The primary endpoint was the composite of any stroke, myocardial infarction, or death during the perioperative period and all-cause mortality within 4 years of CEA. The associations between clinical outcomes after CEA and subclinical CAD were analyzed. RESULTS Concomitant subclinical CAD was observed in 81 patients (11.5%). These patients did have a higher incidence of perioperative cardiac damage (13.6% vs 0.5%, p < 0.01), but they had similar primary endpoint incidences during the perioperative period (2.5% vs.1.8%, p = 0.65) and similar estimated 4-year primary endpoint rates (13.6% vs 12.4%, p = 0.76) as the patients without subclinical CAD. Kaplan-Meier survival analysis showed that the 2 groups had similar rates of overall survival (p = 0.75). CONCLUSIONS Patients with subclinical CAD can undergo CEA with acceptable short- and long-term outcomes provided they receive selective coronary revascularization and optimal perioperative medical treatment.
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Affiliation(s)
| | | | | | - Jong-Young Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | | - Min-Ju Kim
- Biostatistics Collaboration Unit, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea; and
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Galyfos G, Aggeli K, Sigala F, Karanikola E, Zografos G, Filis K. Preoperative Cardiac Assessment before Carotid Surgery: Should Perhaps Things Change? Ann Vasc Surg 2016; 30:331-5. [DOI: 10.1016/j.avsg.2015.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/13/2015] [Accepted: 07/27/2015] [Indexed: 11/16/2022]
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Grobben RB, Vrijenhoek JEP, Nathoe HM, Den Ruijter HM, van Waes JAR, Peelen LM, van Klei WA, de Borst GJ. Clinical Relevance of Cardiac Troponin Assessment in Patients Undergoing Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2015; 51:473-80. [PMID: 26553374 DOI: 10.1016/j.ejvs.2015.09.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 09/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Myocardial infarction (MI) is a frequent complication of carotid endarterectomy (CEA), yet most events are silent. Routine post-operative monitoring of cardiac troponin was implemented to facilitate timely recognition of MI and stratify high risk patients. The aim was to evaluate the incidence of troponin elevation after CEA and its association with adverse cardiovascular events. METHODS This analysis included patients ≥60 years old who underwent CEA, whose troponin-I levels were routinely monitored post-operatively and were included in a cohort study that assessed clinical outcomes. A clinical troponin cutoff of 60 ng/L was used. The primary endpoint was the composite of MI, stroke, and cardiovascular death. Secondary endpoints were MI, stroke, coronary intervention, cardiovascular death, and all cause death. RESULTS 225 consecutive patients were included in the analysis. Troponin elevation occurred in 34 patients (15%) and a post-operative MI was diagnosed in eight patients. After a median follow up of 1.8 years (IQR 1.0-2.6), the primary endpoint occurred in 29% of patients with troponin elevation versus 6.3% without (HR 5.6, 95% CI 2.4-13), MI in 24% versus 1.6% (HR 18.0, 95% CI 4.7-68), stroke in 5.9% versus 4.2% (HR 1.4, 95% CI 0.3-6.7), coronary intervention in 5.9% versus 2.6% (HR 2.7, 95% CI 0.5-14), cardiovascular death in 5.9% versus 0.5% (HR 11.8, 95% CI 1.1-131), and all cause death in 15% versus 5.8% (HR 3.0, 95% CI 1.0-8.7), respectively. Incidences of the primary endpoint and all cause mortality in patients with a post-operative MI versus "troponin only" were 25% versus 7.7% and 25% versus 12%, respectively. CONCLUSION Troponin elevation after CEA occurred in 15% of patients. The incidence of adverse cardiovascular events was significantly higher in patients with troponin elevation, which was mainly attributable to silent non-ST segment elevation MIs that occurred in the early post-operative phase.
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Affiliation(s)
- R B Grobben
- Department of Cardiology, University Medical Center Utrecht, The Netherlands; Department of Anesthesiology, University Medical Center Utrecht, The Netherlands.
| | - J E P Vrijenhoek
- Department of Experimental Cardiology, University Medical Center Utrecht, The Netherlands; Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands
| | - H M Nathoe
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - H M Den Ruijter
- Department of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
| | - J A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, The Netherlands
| | - L M Peelen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - W A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands
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Galyfos G, Zografos G, Filis K. Regarding "Cardiac Morbidity of Carotid Endarterectomy Using Regional Anesthesia Is Similar to Carotid Stent Angioplasty". Vasc Endovascular Surg 2015; 49:45-6. [PMID: 26088944 DOI: 10.1177/1538574415587513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- George Galyfos
- First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
| | - Georgios Zografos
- First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
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Illuminati G, Ricco JB. Re: 'long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease'--reply. Eur J Vasc Endovasc Surg 2015; 50:264. [PMID: 26003798 DOI: 10.1016/j.ejvs.2015.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 04/17/2015] [Indexed: 11/25/2022]
Affiliation(s)
- G Illuminati
- "F. Durante" Department of Surgical Sciences, University "La Sapienza", Rome, Italy
| | - J-B Ricco
- Department of Vascular Surgery, University of Poitiers, Poitiers, France.
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Galyfos G, Sigala F, Aggeli K, Filis K. Re: 'long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease'. Eur J Vasc Endovasc Surg 2015; 50:263-4. [PMID: 26001321 DOI: 10.1016/j.ejvs.2015.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- G Galyfos
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece.
| | - F Sigala
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - K Aggeli
- First Department of Cardiology, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - K Filis
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Cardiac Troponin I after Carotid Endarterectomy in Different Cardiac Risk Patients. J Stroke Cerebrovasc Dis 2015; 24:711-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 11/16/2014] [Accepted: 11/22/2014] [Indexed: 11/18/2022] Open
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Galyfos G, Tsioufis C, Theodorou D, Katsaragakis S, Zografos G, Filis K. Predictive Role of Stress Echocardiography before Carotid Endarterectomy in Patients with Coronary Artery Disease. Echocardiography 2014; 32:1087-93. [DOI: 10.1111/echo.12826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- George Galyfos
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Constantinos Tsioufis
- First Department of Cardiology; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Dimitris Theodorou
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Stilianos Katsaragakis
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Georgios Zografos
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
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Cardiac damage after carotid intervention: a meta-analysis after a decade of randomized trials. J Anesth 2014; 28:866-72. [DOI: 10.1007/s00540-014-1843-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
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Filis K, Tsioufis C, Galyfos G. Letter by Filis et al Regarding Article, “Non-ST–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement”. Stroke 2014; 45:e89. [DOI: 10.1161/strokeaha.114.004894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Konstantinos Filis
- Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Department of Cardiology, University of Athens Medical School, Ippokration Hospital, Athens, Greece
| | - George Galyfos
- Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
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Regarding 'carotid endarterectomy national trends over a decade: does gender matter?'. Ann Vasc Surg 2014; 28:1082-3. [PMID: 24530721 DOI: 10.1016/j.avsg.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/02/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
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